What is the next step in management for a patient with a history of reducible inguinal hernia who now presents with constant abdominal pain, abdominal tenderness, and no palpable inguinal mass or tenderness?

Urgent Hernia Repair Surgery (Option B)

This patient requires urgent surgical exploration for a likely spontaneously reduced strangulated inguinal hernia with possible bowel compromise. The absence of a palpable inguinal mass after a history of chronic reducible hernia with acute constant pain and new abdominal tenderness strongly suggests the hernia spontaneously reduced with potentially ischemic bowel now in the abdomen 1.

Clinical Reasoning

Why This is a Surgical Emergency

• Spontaneous reduction of strangulated hernias does not exclude bowel ischemia - the bowel may have been compromised during incarceration and then reduced back into the abdomen while still ischemic 1
• The transition from intermittent, reducible pain to constant pain with abdominal tenderness indicates progression from simple incarceration to likely strangulation 1, 2
• Delayed diagnosis beyond 24 hours is associated with significantly higher mortality rates in strangulated hernias 2, 3
• Emergency surgery is needed for unsuccessful manual reduction, and in this case, the hernia appears to have auto-reduced with concerning abdominal findings 1

Diagnostic Laparoscopy is Critical Here

• Diagnostic laparoscopy (hernioscopy) is specifically recommended to assess bowel viability after spontaneous reduction of strangulated groin hernias 1
• This approach can prevent unnecessary laparotomy if bowel is viable, or identify necrotic bowel requiring resection 4, 3
• Hernioscopy decreases hospital stay and complications compared to observation alone 4

Why Other Options Are Inappropriate

Option A (Reassure and Discharge) - Dangerous

• Absolutely contraindicated - this patient has red flags for bowel strangulation including constant pain and abdominal tenderness 2, 3
• Delaying repair of strangulated hernias leads to bowel necrosis and increased morbidity/mortality 4, 3

Option C (CT Abdomen/Pelvis) - Delays Definitive Care

• While CT findings, lactate, CPK, and D-dimer can predict bowel strangulation 1, imaging should not delay surgical exploration when clinical suspicion is high 2
• The clinical picture already warrants urgent surgery - CT would only delay definitive management 1

Option D (Hernia Repair After 2 Days) - Too Late

• Same-admission surgery is indicated for all patients with successful manual reduction of complicated hernias 1
• Waiting 2 days risks progression of bowel ischemia if present 2, 3

Surgical Approach

Initial Exploration

• Begin with diagnostic laparoscopy to assess bowel viability 1, 4
• If bowel appears viable, proceed with laparoscopic hernia repair 1

If Bowel Compromise is Found

• Open preperitoneal approach is preferable when bowel resection is needed 4
• Prosthetic repair with synthetic mesh can be performed even with intestinal strangulation and bowel resection without gross spillage (clean-contaminated field, CDC class II) 1
• For contaminated fields with bowel necrosis/spillage, primary repair is recommended for small defects (<3 cm), or biological mesh if direct suture not feasible 1

Common Pitfalls to Avoid

• Do not be falsely reassured by the absence of an inguinal mass - spontaneous reduction with ischemic bowel in the abdomen is a recognized dangerous scenario 1
• Do not delay for imaging studies when clinical findings suggest strangulation 1, 2
• Do not assume the patient is stable for delayed repair - abdominal tenderness after hernia history is a surgical emergency until proven otherwise 2, 3